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INSTRUCTIONS FOR COMPLETING FORM "B"
<br /> GENERAL INSTRUCTIONS
<br /> Section 2711 of Title 23, Division 3, Chapter 16, California Code of Regulations and sections 25286, 25287, and 25289
<br /> of Chapter 6,7, Division 20, Health and Safety Code require tank owners to apply for an UST operating pen-nit.
<br /> 1, One FORM "B" shall be completed to,,each tank for all NEW PERMITS, PERMIT CHANGES, REMOV-
<br /> ALS and/or any other TANK INFORMATION CHANGE,
<br /> 2, This form Should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER-
<br /> GROUND TANK INSPECTOR.
<br /> 1 Please type or print clearly all requested Information.
<br /> 4Use a hard point writing instrument, you are making 3 copies,
<br /> 5. Tank owners must submit a plot plan to the local agency showing the location of the USTs with respect
<br /> to buildings, and lan,,dma-rks 12711 (a)(8)CCRI,
<br /> 6. Tank owners must submit documentation showing compliance with state financial responsibility require-
<br /> ments to the local agency for petroleum USTs [27111 (a)(11) CCRIJ,
<br /> TOP OF FORM: MARK ONLY ONE ITEM
<br /> 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed,
<br /> 2. Indicate the DBA or Facility name where the tank is installed,
<br /> L TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY
<br /> A. Indicate owners tank ID # - If there is a tank number that is used by the owner to identify the tank (ex,
<br /> AB70789).
<br /> B, Indicate the name of the company that manufactured the tank(ex. ACME TANK MFG).
<br /> C, Indicate the year the tank was installed (ex, 1987).
<br /> D, Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc,).
<br /> 11, TANK CONTENTS
<br /> A. 1, IF It VEHICLE FUEL, check box 1 and complete items B& C,
<br /> 2, If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B&D,
<br /> BCheck the appropriate box,
<br /> C. Check the'type of MOTOR VEHICLE FUEL(if box 1 is checked in A),
<br /> D. Print the chemical name of the hazardous substance stored in the tank and the C,A,S,#, (Chemical
<br /> Abstract Service number), if box I is NOT checked in A.
<br /> Ill, TANK CONSTRUCTION- MARK ONE ITEM ONLY IN BOX A, B, C & D
<br /> 1 Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING andCORROSION
<br /> PROTECTION,
<br /> 2, If OTHER, print in the space provided,
<br /> lv. PIPING INFORMATION
<br /> 1, Circle."A" if above ground circle"U" if underground, and circle both if applicable,
<br /> 2, If UNKNOWN circle; or if OTHER, print in space provided,
<br /> 3. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping,
<br /> V. TANK LEAK DETECTION
<br /> I indicate the LEAK DETECTION systern(s) used to comply with the monitoring requiremeRts for the tank,
<br /> VL INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1 ESTIMATED DATE LAST USED - MONTH JYEAR (January, 1988 or 01/88)
<br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons),
<br /> 3, WAS TANK FILLED WITH INERT MATERIAL? Check"'Yes"or"No".
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI-
<br /> CATED [see section 2711 (a){12) CCR]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state gpde-rg round storage tank identification number is composed of the two digit county number,the three digit
<br /> jurisdiction number,the six digit facility number and the six digit tank number, The county and jurisdiction numbers are
<br /> predetermined and can be obtained by calling the State Board(916)22 -i301 'the facility number must be the same as
<br /> shown in forrri"A". The tank nuc ber.may%be assigned by the local agency,however,this number must be numerical and
<br /> cannot contain an alphabet. If the loom,agencyprefern the State Board to assign the tank number, please leave it blank,
<br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU-
<br /> RACY OF,THE INFORMATION, THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE
<br /> "LOCAL AGENCY USE ONLY" INE MATION BOX. THE LOCAL AGENCY SH AIN IHE ORIGINAL Al
<br /> YELLOW COPIES, THE Pit SHOULD BE RETAINED BY THE TANK ER.
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